Nasal Secretion Insufficiency Syndrome (New Concept of Ozena)

Journal of Lung, Pulmonary & Respiratory Research

Online Report Open Access Nasal secretion insufficiency syndrome (new concept of ozena)

Abstract Volume 7 Issue 2 - 2020 The patient complained of nasal odor and was referred to a psychiatrist by the Department Toshiro Takami of Otolaryngology as a case of olfactory reference syndrome. The patient had a strong nasal Akiyama hospital, Japan odor. The doctor denied the existence of atrophic rhinitis and rhinophobia. If you look around the internet, there are many who suffer from similar conditions. Almost Correspondence: Toshiro takami, Akiyama hospital, 47-8 Kuyamadai Isahaya-shi Nagasaki-prefecture, 854-0067, Japan, all of them complain of an unusually dry nose. It was thought that Pseudomonas aeruginosa Tel 080-5211-3990, Email or some fungus grew abnormally in the devastated nasal mucosa of the endogenous nasal cavity, and due to inadequate nasal secretion, the bacterial metabolites could not be forced Received: August 22, 2020 | Published: September 18, 2020 down the throat or other parts of the body, giving off a strong nasal odor. This disorder is often neglected or diagnosed by psychiatrists as olfactory reference syndrome. The term “nasal secretion insufficiency syndrome” is used to describe this condition. This is a new concept of nasal odor disease, which remains unnoticed, partly because there is no crusting or atrophy of the native nasal cavity, and partly because endoscopy reveals only the devastation of the nasal mucosa, and partly because it is hidden behind the veil of atrophic rhinitis and ozena. In all seven cases, the foul odor is weakened, albeit temporarily, by the use of saliva- enhancing drugs.

Keywords: new concept of ozena, nasal secretion insufficiency syndrome, olfactory reference syndrome, drugs that stimulate saliva production

Introduction in old age, that the incidence rate in females was twice as high as that in males, and that the odor in female patients often became stronger The odor is weaker than that of atrophic rhinitis and ozena due to or weaker in accordance with their menstrual cycles. It was suggested the abnormal growth of some bacteria in the mucosa of the nasal cavity that hormones had a significant effect on ozena. There was also a of the nasal cavity without forming a crust. When patients complain of strong theory of autonomic neuropathy, which suggested that a very nasal odor, they are not applicable to the concept of atrophic rhinitis large number of patients were nervous and that the bacterial infection or ozena, so most of them are referred to the psychiatry department was secondary to the bacterial infection. for olfactory reference syndrome.1 The nasal secretion insufficiency syndrome is the condition of the nasal secretion insufficiency, which The incidence of atrophic rhinitis and ozena has continued to means that the tissue secreting nasal juice is damaged and the nasal decline since 1950, and nowadays, at least in developed countries, the secretion is decreased. The causes of the disease are thought to be incidence of atrophic rhinitis and ozena is almost non-existent. This diverse. The most common cause is the gradual or rapid damage to author believes that this is due to the fact that high doses of female the nasal mucosa caused by rhinosinusitis. Other causes are more hormones have become the norm in modern livestock farming and common in those working in freezers. aquaculture. In the rural areas where people cannot eat milk and meat due to modern livestock farming and aquaculture, atrophic rhinitis Although the frequency of this disorder is high, almost all have and ozena still occur at a relatively high rate. been diagnosed as olfactory reference syndrome. However, the stench can be so strong that many refuse to be in the same room.2 There is a social networking site for people suffering from odor, with more than 200 registered users, mostly women, ranging in age The number of tormentors has increased dramatically, and it is from 14 to 56 years old. People who suffer from a wide range of odors now very common for people to be tormented as “stinky” people. such as bad breath, nasal odor, body odor, and the gas form of irritable Many of them have become socially withdrawn or withdrawn. bowel syndrome (IBS) have registered on the site. Until a few years Atrophic rhinitis and ozena is mentioned in ancient Egyptian ago, the name “Friends of the Nasal Odor Sufferers” was used because documents as a mysterious disease. Atrophic rhinitis and ozena was the organizer suffers from nasal odor. It is believed that many people proposed by B. Frankel to be accompanied by three main signs of with bad breath and body odor have nasal odor but are not aware of it. “foul odor, atrophy, and crusting” and is believed to have laid the Many of the participants in this SNS are afraid of self-odor, but 3 groundwork for a single disease. some of them can only think of it as really smelly. These were thought Previously, the frequency of atrophic rhinitis and ozena was high to be inadequate nasal secretion for a variety of reasons. The cases are worldwide, and the etiology of the disease has been the subject of much described below. debate. It was known empirically that the administration of female In all of the following seven cases, the foul odor subsided, though hormones was effective, that the disease often resolved spontaneously temporarily, when medication to promote salivation was taken.

Submit Manuscript | http://medcraveonline.com J Lung Pulm Respir Res. 2020;7(2):56‒60. 56 ©2020 Takami. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially. Copyright: Nasal secretion insufficiency syndrome (new concept of ozena) ©2020 Takami 57

The reason for this is that when saliva secretion is promoted, nasal on the Internet. In the spring of his sophomore year of high school, he secretion is also promoted. went to see a famous elderly ENT doctor at the urging of his parents and was diagnosed with atrophic rhinitis (no CT or endoscope was Case used). However, atrophic rhinitis was ruled out by MRI as there was no atrophy of the nasal gland. (Case 1) 54-years-old, male In the spring of his sophomore year of high school, his severe Family history: father and sister and nervousness (sister and two acne, which had plagued him since sixth grade, went into dramatic brothers) remission. This coincided exactly with the period when he no longer Personality: Stubborn, enthusiastic, picky, gentle, nervous and struggled with the nasal discharge that came up during class. The case obsessive tendencies believes that around this time, due to her sister’s severe acne, her diet changed to emphasize vegetables, and this altered her gut microbiota, Life history: Good grades since childhood (for privacy reasons) which in turn altered the flora of her skin and intrinsic nasal cavity. History: At the age of 28, he developed depressive disorder, and his He believed that he had a strong nasal odor from his sophomore condition has continued to be mild and severe. year of high school, or at least the winter of his junior year of high At the age of 32, he developed psychogenic pollakiuria, which has school, when he stopped struggling in class because of his nasal continued to this day. discharge, if memory serves (I remember avoiding it while studying in the library in the winter of my junior year of high school). Current medical history: In the winter of the first year of elementary school, he developed rhinosinusitis. Since then, he suffered greatly Further traversing the memory, the nasal odor started in my junior from nasal discharge during class. In the winter of the second year of year of middle school when he started eating a lot of meat. he began junior high school, he noticed that the left nasal bone was swollen. to think that the meat was covered in antibiotics and that this killed Although the middle nasal cavity was forming (Figure 1) the case was off Staphylococcus lugdunensis in the endemic nasal cavity, allowing left alone without concern. Staphylococcus aureus to grow abnormally in the endemic nasal cavity.4,5 He imported mupirocin, which is widely used in surgery to selectively kill cocci such as Staphylococcus aureus, and used it privately, but the dryness of the intrinsic nasal cavity did not diminish (the smell was unknown). When he noticed nasal odor, he injected lactobacillus solution into her nasal cavity, but he found out that it was effective for about one hour, so he now inhales horse oil in his nasal cavity. However, he found that the effect was about one hour, so he now use horse oil for intranasal inhalation, which is not as strong a cleansing agent, but the effect lasts a long time. He also reads books on horse oil and inhales horse oil into the nasal cavity in the hope that the oil will regenerate the devastated nasal mucosa. He always wears a mask to reduce the thirst of his nasal passages, but his nasal passages feel very dry, and only a little watery nasal secretions are occasionally emitted. When he touches the nasal mucosa of his nasal cavity with a cotton swab, he can see that it is rough. Figure 1 Middle turbinate honeycomb in case 1. He was referred to a psychiatrist because he thought he had fungal Since the spring of his sophomore year of high school, his rhinosinusitis and was diagnosed as having fungal rhinosinusitis. rhinosinusitis has become milder or his secretions have decreased, There is no internal disease. There is no known reaction of the and he is no longer bothered by the nasal discharge that comes out surroundings, i.e., coughing and sniffing. during class. (Case 2 and below are six cases of “Nasal Secretion Deficiency He have been suffering from bad breath for many years since he Syndrome” probable.)6 graduated from high school. He thought his bad breath was caused by chronic gastritis. (Case 2) 31-years-old, male A few years ago, he self-diagnosed that his bad breath was caused Current medical history: He claims to have developed odorophobia by gastroesophageal reflux disease and underwent gastrointestinal naturally since he began working in a freezer at age 19. contrast and 24-hour esophageal pH monitoring at a university 1. He visited an ENT, but was diagnosed with auto-odorophobia. hospital. No history of psychiatric consultations. After 24-hour gastroesophageal pH monitoring, he began to think 2. He works diligently at his job without a break. He still works that his odor was nasal odor and not halitosis. It was around the time in the freezer most of the time. He rarely has close contact with when he was agonizing over how to cure his nasal odor, when he people at work. He has never been bullied. read about the “Association of Friends Suffering from Nasal Odor”

Citation: Takami T. Nasal secretion insufficiency syndrome (new concept of ozena).J Lung Pulm Respir Res. 2020;7(2):56‒60. DOI: 10.15406/jlprr.2020.07.00229 Copyright: Nasal secretion insufficiency syndrome (new concept of ozena) ©2020 Takami 58

3. He can’t let people ride in his car because he think it smells He found a website called “The Association of Friends Suffering bad, and when he go to people’s houses to play, he always wash from Nasal Odor,” where he thought he was suffering from his nasal passages in the car with a device that washes them rhinosinusitis. He wrote: “I have been told by an ENT specialist with saline solution or something else before he go into people’s that there was no crusting or atrophy of the nasal cavity, but it could houses. be atrophic rhinitis and that the mucous membrane was severely damaged. 4. If he doesn’t wear a mask to bed on a tired day, he gets nosebleeds when he wakes up because it’s too dry. One ENT clinic wrote a referral to a psychiatrist and he have seen a psychiatrist. The psychiatrist diagnosed him with a fear of self- 5. He has a serious and honest personality. He always wears a odorization and prescribed alprazolam and sulpiride. His personality mask, but he only occasionally has a small amount of watery is amicable and highly social. He has three children and his family is nasal discharge that is not viscous. No nasal hair. There is no happy. He has no medical problems. There are no known reactions, internal disease. There is no known reaction of the surroundings, i.e. coughing and sniffing.9,10 i.e., coughing and sniffing. (Case 5) 29-years-old, female (Case 3) 37-years-old, male Current medical history: She had been treated by an ENT clinic for Current medical history: When he was in high school, he visited rhinosinusitis since her early elementary school years. She has been several ENT clinics because he claimed that during the winter he taking antibiotics since her early elementary school days. It seems that fell asleep in front of a hot air heater and inhaled hot air for a long she has been giving off a bad smell since her junior high school days, time, which caused pressure ulcers to form in his native nasal cavity but it’s not clear, maybe she has been giving off a bad smell since her and emitted nasal odor. One of the ENT departments diagnosed him elementary school days. with olfactory reference syndrome and recommended that he see a psychosomatic physician, who referred him to a psychosomatic The self-introduction on the “odor trouble social network” reads physician and he continues to see a psychosomatic physician. He still as follows goes to a psychosomatic physician because he needs sleeping pills.7,8 “I haven’t laughed from my heart in years. He works at the Y Department and has never been tormented. This She have learned to laugh with her mouth closed because when she is presumably due to the fact that his case work at the Y Department laugh, she give off a smell. involves very little close contact with people; he works in a department at the Y Department that has a very high number of night shifts; when She have learned to keep conversations short and to use words as he joined the Y Department, he was concerned about nasal odor, so he much as possible. chose his current department, which most people avoid. She make an effort to breathe in as much as she can on her own. He wrote: “Dry winter is the problem, the smell gets worse when it’s dry” and “I’ve been applying Vaseline and wearing masks lately The people around her don’t know about this effort. to prevent dryness. And that’s why they offer her breath care. They offers me a His personality is serious and straightforward. He always wears Fabreeze. a mask, but only occasionally has a small amount of watery nasal They are doing this out of kindness, and that action makes her discharge. He has no medical problems. There is no known reaction suffer even more. to his surroundings, i.e. coughing and sniffling. She love kids, and She want to be married. (Case 4) 56-years-old, male But she have been shutting everything down because she feel like Current medical history: He had bad ears and nose since the early she should not be in a relationship because of this smell. years of elementary school and had to go to an ENT clinic. When he was in junior high school and high school, he had a hard time in class “I’m all about work. LOL. because he had a lot of nasal discharge. I’m in the customer service industry, ready to be a nuisance. After graduating from high school, he joined the Tokyo branch of The smelly, dark, and unworkable ones, than the ones who can’t Company A. He worked on the floor with nearly 200 people. There, work. he is accused of “smelling” by the company’s employees. However, he didn’t pay much attention to it. I want a stinky, but energetic, workmanlike guy. When he was 30 years old, he was transferred to the Osaka branch. I think it’s only recently that I’ve started to go for it. Here too, he works on the floor with nearly 200 people. Rumors of I’ve been to a famous dentist. I had a physical exam. I even took his time in the Tokyo branch have spread, and the same employees a gastroscope. I’ve even tried herbal medicine. And yet, I couldn’t have been talking behind his back about the “smell” of the office. It figure out where or what was giving off this smell. It was six months happened frequently that younger employees would come near the ago that I realized it was nasal odor. cases and smell them and say they “stunk”. The case was distressed and underwent surgery for rhinosinusitis at a university hospital. It is When will I ever be able to truly laugh?” presumed that this kind of torment could have happened because the She claims that her nasal odor often becomes stronger and nasal workplace had a lot of time on his hands. odor almost disappears in response to her menstrual cycle.

“A couple of ENTs told me that the mucous membranes in my The point is, as long as you’re able to excrete the pus, the smell nose were very rough,” he says, “I could barely smell it, and the ENT isn’t too bad. said, The nerve cells in my sense of smell have been abolished. Why If excretion is blocked and pus builds up in the maxillary sinuses, did you let it go? In summer I smelled rotten fish, and in autumn and etc., a foul odor will ensue! This is the kind of scheme I’m thinking winter I smelled a fart. His character is serious and straightforward. of.” Watery nasal discharge is occasionally slight. There is no internal disease. She is hypersensitive to the reactions of her surroundings, She writes. “I severely dislike being called “olfactory reference such as coughing and sniffing. syndrome” and “overly concerned”. She don’t have an internal disease. She is extremely sensitive to the reactions of her surroundings, i.e. (Case 6) 48-years-old, female coughing and sniffing. Current medical history: In the fourth grade of elementary school, he developed rhinosinusitis. After entering junior high school, he had (Case 7) 28-years-old, female frequent nasal congestion and difficulty breathing through his nose Current medical history: She is not sure when she started to smell at night. At the same time, she found out that her nose was emitting bad. At least when she started working, she began to have a nasal odor. a foul smell. She went to the ear, nose and throat clinic to complain about her nasal odor, but she was lightly treated. Around this time, When she goes to work, she inhales horse oil in her nasal passages her classmates called her “stinky” and tormented her severely by the at home, which is not stinky in the morning, but in the afternoon she female guard. In the second year of junior high school, she started emits a foul odor, which is annoying to the people around her and taking an over-the-counter Chinese herbal medicine for rhinosinusitis disliked by the people around her as “smelly”. The fact that horse and ozena, which was said to be effective. After researching in the oil reduces nasal odor is a fact she learned about and practiced in library, she realized that her condition was probably due to her own “Friends of Nose Odor”. odorous nose disorder. When she was in junior high school, she was She says that nasal rinsing with saline solution is only effective for told that she smelled “fart smell” and “feces smell”. about two hours. When she was in her twenties, she went to an ENT clinic and was She avoids romance because she thinks she’s stinky. told that “the inside of her nose is completely black! She must be puking on a cigarette like Godzilla! (Case does not smoke.) At that Her personality is honest and serious. She is also thought to have time, her rhinosinusitis was so bad that she was emitting a lot of green a mixture of nasal secretion insufficiency syndrome and olfactory nasal discharge, and she was fussed over at work, pointing to the reference syndrome. place where the patient was, saying, “That area smells squidgy and **Thus, from the above seven cases, men seem to be insensitive to fishy!” This was right after taking antibiotics for seven days, and it is surrounding reactions, that is, coughing and sniffing, but many men assumed that Pseudomonas aeruginosa had been growing abnormally. are hypersensitive to surrounding reactions and at least concurrent She had seen many ENT doctors, but one ENT told her that she olfactory reference syndrome in this SNS. **All three of the women had “weak atrophy of the nasal cavity, not atrophic rhinitis, but weak listed above concurrent olfactory reference syndrome. atrophy of the nasal cavity, with very rough nasal mucosa. Discussion She imported Mupirocin privately and used it, but stopped using it after a few days when it came to her stomach (stomach upset) and she It is not clear what fungus destroys the native nasal mucosa, which didn’t feel any effect. contains nasal glands and goblet cells that produce nasal secretions. She claims that her nasal odor becomes stronger or weaker Many nasal odor sufferers claim that taking common antibiotics depending on her menstrual cycle, especially during menstruation (she will dramatically reduce the odor for a few days. can’t smell it herself, so she judges it from the reactions of others). Many nasal odor sufferers complain of slight nasal discharge and She writes: “After taking the medicine (note: etizolam), the a strong dry feeling. This may be due to the strong irritation of the reactions of people around me, such as coughing and sniffing, nasal mucosa. disappear completely,” “My son also has nasal odor,” and “When she It is believed that nasal odor becomes stronger in response to catches a cold and has a runny nose, the odor gets weaker”; “I used to the menstrual cycle and that nasal odor becomes stronger during import etizolam from the Internet. menstruation. This is because the microbiota in the nasal cavity Recently, she said, she has been receiving many complaints changes in response to the menstrual cycle. This is consistent with about the “smell of farts” and “feces.” She is severely concerned the ancient theory that hormones are the etiology of atrophic rhinitis about people with strong breath odor at work and elsewhere. She is and rhinorrhea, and that the odor of atrophic rhinitis and rhinorrhea extremely sensitive to odors. At home, she makes her children check increases during menstruation. Several women who participated in the smell, and when he say, “I don’t have a smell,” she criticizes him, this “odor worries social networking service” did not recognize the telling him to tell the truth, until he cry. odor themselves, so they guessed it based on the reactions of their neighbors, but their sensitivity to the reactions of their neighbors was “When the smell is bad, there’s no pus or nasal discharge (my extremely high, so we believe they were correct in their judgment. nose gets dry). Even if the nasal cavity is rinsed with saline at night, the next When the smell is lessened, it feels like pus is coming out and my morning the nasal cavity still emits a foul odor. Nasal rinsing with nose is moist. saline may be effective for a short time, but the effect is not long, often lasting up to 2 hours.

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Citation: Takami T. Nasal secretion insufficiency syndrome (new concept of ozena).J Lung Pulm Respir Res. 2020;7(2):56‒60. DOI: 10.15406/jlprr.2020.07.00229